Living with cancer is a complex, recursive physical, existential and psychosocial challenge. The
biology of the disease, the physiological effects of the treatments on the brain and body and the
psychosocial aspects are all important and mutually interactive. “Brain fog” and its range of
manifestations is frequent and troublesome as are anxiety and depressive symptoms and fatigue
etc. It is important to address these psychophysiological states as part of the ‘cancer journey’ to
enhance coping, recovery, functioning, well being and physical outcomes. Sorting sleep is an
important part of this journey, from understanding circadian influences on response to
chemotherapy and other treatments through to psychological coping and quality of life.
Self help and psychological therapies typically have a predominant focus on thoughts and
feelings and to a lesser extent, behaviour. An additional approach encourages one to first note
and acknowledge thoughts and feelings and related behavioural urges, then assess one’s
associated psychophysiological arousal state; and then use this apprehension to regulate one’s
arousal state before ‘looking again’ to the self-in-world context before taking ‘action’. Often,
changing arousal state enables different perceptions, thoughts, feelings and behaviours to
Some key strategies (can be provided in a next article) for self regulation, intentionally using
vision, behaviour and breathing to change the brain’s states, will enable changes in the arousal
state and thus in emotions and thoughts, permitting a different subjective experience.
Sleep is one of our diurnal biobehavioural states that is necessary for wellbeing, adaptive
functioning and regulation. This article in summarising factors affecting adequate duration and
quality of sleep, will highlight the importance sleep plays in the capacity to self regulate and cope
in achieving improved well being and health. Adequate sleep enhances response and outcomes
from whatever treatment one is having.
Circadian set & protect strategies for adequate duration and quality of sleep
Each day begins with adequate sleep in the nights before.
Adequate functioning and well being depends on the adequacy of sleep and this means getting
enough sleep and uninterrupted sleep so that we wake refreshed and can remain alert and
functional through the day.
Inadequate sleep results in poor attention and concentration, mood problems (anxiety and low
mood and emotional reactivity), problems with memory and learning, impulsivity and poor decision
making, impaired empathy and social skills and suboptimal occupational, sporting and driving
Prolonged sleep inadequacy is linked to a wide range of mental and physical health problems – for
instance, increases the risk of heart disease, hypertension, obesity, diabetes, cancer and dementia.
Sleep problems undermine sustainable weight loss, response to treatments and predict poor
outcomes and recidivism in substance dependency and misuse. Sleep problems are associated with
prolonged recovery times after illness and injury.
Common sleep problems include snoring and obstructive sleep apnoea, prolonged delay getting off
to sleep, waking through the night, waking unrefreshed and daytime sleepiness. Adults need
around 7-8 hours or so sleep a night.
Sleep is an essential physiological process but can be disrupted by lifestyle and other habits. Sleep
is entrained by the light-dark cycle and also by the timing of our eating/feeding behaviours in
relation to the circadian sleep-wake cycle, exercise (type, amount and timing), coffee and alcohol
(amount and timing) and other substance use/abuse. Alcohol and other substances commonly
overused or abused disrupt the clock genes and other biological processes involved in circadian
sleep-wake regulation. Many medications including those prescribed/taken for sleep actually
disrupt sleep – for instance the sedatives like benzodiazepines sedate but abnormalise sleep.
Knowledge of these processes, implementing the relevant routines and behaviours and making
sleep a non-negotiable priority are all important if we are to achieve adequate sleep and in turn
enhance our well being, functioning and maximise our health span.
Strategies to set and protect your circadian sleep-wake cycle
If you snore you need to get an assessment – this involves an overnight sleep study to quantify how
often and in what stages of sleep and the sleeping positions in which you snore and whether your
oxygen levels drop as a result. The neuroCare assessments and the Epsworth Sleepiness Scale can
provide an indication of snoring as can your partner reporting/complaining about snoring and
further encourage an overnight sleep study.
The day-night/light-dark cycle are the major triggers of the sleep-wake cycle. Getting up at the same
time each morning, having an adequate breakfast and getting adequate sun exposure outside
within the first few hours of getting up will set the cycle. Ideally this is done by a 20-30-minute walk
or similar exercise, without the use of sunglasses. This sun exposure with activity is ideally repeated
at least several times throughout the day as both sun exposure and exercise/activity will enhance
sleep quality the subsequent evening as well as engender better mood, wakefulness and cognitive
functioning during the day. Spending the day inside the house/office invariably means that light
exposure and activity levels will be insufficient to adequately activate the sleep-wake cycle and will
also result in less sleep pressure accumulating over the course of the day that assists getting off to
sleep each night.
Eating should occur within an 8-10 hour window each day – starting with the first sip of tea/coffee
and first mouthful of food at breakfast and the last meal of the day should be completed before that
time window is up. This eating routine has been shown to enable optimal entrainment one’s
circadian metabolic and physiological rhythm so that it is in phase with the day-night/light-dark
It is important to drink water regularly throughout the day. We have a greater water intake
requirement during the day and dehydration can be associated with sleepiness, brain fog and
fatigue. Caffeinated drinks should not be consumed after mid-morning as caffeine will likely disrupt
sleep when taken after this time. Alcohol is a potent disruptor of sleep – while it initially sedates it
subsequently provokes actual or sub-threshold awakenings and is a potent disruptor of REM/’dream
Exercise is important for sleep and general health and wellbeing but should be completed at least
3-4 hours prior to anticipated bedtime. Eating and exercising too close to bedtime disrupts sleep.
We are often not active enough over the day, sitting way too much, and this can be addressed with
recurrent walking outside, without sunglasses several times a day.
A wind down time for several hours prior to bedtime also facilitates sleep. At this stage activities
such as meditation, slow abdominal breathing and stretching can be helpful to calm and quieten
the mind and overall physiological arousal.
All the light sources in the domestic context, including phones, tablets and TV emit enough blue
light to disrupt melatonin production and disrupt sleep onset and maintenance. Wearing blue light
blocking glasses for two or more hours prior to anticipated bedtime (approximately 10 hours prior
to wakeup/get up time) protects the eyes from ambient blue light enabling the gradual surge of
melatonin that signals the brain to ‘switch into’ sleep mode. In aiming to get about 8 hours sleep a
night one needs to establish a routine so one is in bed for approximately 8.5 hours.
The bedroom needs to be cool, quiet and dark as a small drop in body temperature is also necessary
for sleep to onset - this is another reason why eating and exercising too close to bedtime disrupts
sleep as metabolic activity and thus body temperature are elevated, opposing the entrainment of
these processes by the light-dark triggers. Light in the bedroom will penetrate the closed eyelids
and disrupt melatonin levels and sleep.
It can take days to weeks to establish this routine and adequately entrain the sleep-wake cycle, so
it is important to persist. The effort is important and worth it especially given that sleep problems
are involved as instigating and maintaining factors for many/most physical and mental health
problems, including mood, substance abuse, weight gain, abdominal and generalised obesity,
cardiovascular and metabolic problems such as type 2 diabetes. Sleep disruption predicts
substance use and misuse and also relapse after a period of controlled use/abstinence. Further
adequate sleep is necessary for learning including the learning inherent in the neuromodulation
treatments offered at neuroCare.
some, further intervention and treatment will be important to establish and consolidate sleep.
- By Mark Ryan (FRANZCP, BCN)
neuroCare Clinics Australia